M. Shechter, R. Beigel, S. Matetzky, D. Freimark, P. Chouraqui.
Statins play an important role in the treatment and prevention of coronary artery disease and atherosclerosis. Currently, however, despite its important qualities, the use of statin therapy in the treatment of CAD patients ranges only between 30 and 60% in Europe, the United States and Israel. A wide gap still exists between the numerous scientific publications demonstrating the beneficial effects of statins and the low rate of implementing the guidelines in practice. A Medline search up to June 2005 on all prospective, double-blind, randomized clinical trials evaluating the impact of intensive statin therapy (any statin dose >40 mg/daily) on clinical outcomes after a 1 year follow-up revealed only eight trials. In all the eight trials, with a follow-up period of 12–60 months, intensive statin therapy was significantly more effective than and at least as safe as placebo or other standard statin regimens. Thus, based on the current evidence-based medicine, intensive statin therapy enables more patients with CAD to achieve the current National Cholesterol Education Program goal for low density lipoprotein, while ensuring a relatively high safety profile.
S. Koton, Y. Schwammenthal, O. Merzeliak, T. Philips, R. Tsabari, B. Bruk, D. Orion, Z. Rotstein, J. Chapman and D. Tanne
Background: Clinical trials have demonstrated the superiority of managing acute stroke in a dedicated stroke unit over conventional treatment in general medical wards. Based on these findings, nationwide stroke unit care programs have been implemented in several countries.
Objective: To assess the effect of establishing a new dedicated acute stroke unit within a department of neurology on indicators of process of care and outcome of acute stroke in a routine clinical setting in Israel.
Methods: Stroke patients admitted to the Sheba Medical Center during the period March 2001 to June 2002 were included in a prospective study according to selection criteria. Data on demographics, risk factors, co-morbidities and stroke severity were collected. Indicators of process of care and outcome were assessed at hospital discharge and 30 days follow-up. Comparison between outcome variables by hospitalization ward was conducted using logistic regression analysis adjusting for confounders.
Results: Of 616 acute stroke patients (mean age 70 years, 61% men, 84% ischemic stroke), 353 (57%) were admitted to general wards and 263 (43%) to the stroke unit. Diagnostic procedures were performed more often, and infection rate was lower in the setting of the stroke unit. Poor outcome (modified Rankin scale ≥3 or death) was present less often in patients managed in the stroke unit both at hospital discharge (adjusted odds ratio 0.5, 95% confidence interval 0.3–0.8) and at 30 day follow-up (adjusted OR[1] 0.6, 95%CI[2] 0.3–0.9). A Functional Independence Measure score ≤90 or death at 30 day follow-up was less frequent among patients managed in the stroke unit than in general wards (adjusted OR 0.5, 95%CI 0.2–0.8).
Conclusions: Improved outcomes and higher adherence to guidelines were observed in patients treated in a stroke unit within a department of neurology. The results suggest that patients with acute stroke should have access to treatment in a dedicated stroke unit.
[2] CI = confidence interval
O. Baron-Epel, A. Haviv, N. Garty, D. Tamir and M.S. Green
Background: Increasing physical activity and thereby reducing a sedentary lifestyle can lower the risk of chronic diseases. Raising the population's involvement in physical activity is a major challenge for public health and healthcare services.
Objectives: To identify subpopulations with a sedentary lifestyle and low levels of adherence to physical activity recommendations.
Methods: The Israel Center for Disease Control performed two national surveys during 2002–2003, interviewing 7,307 Jewish Israelis and 1,826 Arab Israelis over age 21. Respondents were asked if they engaged in physical activity lasting at least 20 consecutive minutes, and if so how frequently: less than once a week, once or twice a week, nearly every day or every day.
Results: Arab respondents were less physically active than Jewish respondents after adjusting for gender, age, level of religiosity, marital status, education, self-reported health, smoking, body mass index, and type of survey. Multiple logistic regression analysis run separately for Jews and Arabs found a more sedentary lifestyle, in both groups, among women, the less educated, those who were married and those with poor subjective health. Among Jews, younger people, increased religiosity, smoking and high BMI[1] were associated with a sedentary lifestyle.
Conclusions: The Jewish population is in need of more targeted and specific interventions for lower adhering subpopulations, such as women, the less educated and those with other risk factors. In the Arab population a more thorough understanding of the benefits of physical activity is needed; however, it seems that a general intervention is required to decrease the prevalence of a sedentary lifestyle all round.
Galinsky, D. Kisselgoff, T. Sella, T. Peretz, E. Libson and M. Sklair-Levy
Background: Mammography is the principal breast cancer imaging technique; however, sensitivity is reduced, especially in dense breast tissue. Magnetic resonance imaging is increasingly used in the detection and characterization of breast cancers. The high sensitivity (95–100%) of MRI is consistently observed, and in many situations, MRI is proving superior to classical forms of imaging. Assessment of its impact on management and outcome is vital if MRI is to become standard in the management of breast cancers.
Objectives: To establish the impact of breast MRI on women undergoing testing in our institution.
Methods: We analyzed 82 cases that underwent MRI between January 2001 and April 2003. Analysis appraised the clinical impact of MRI testing in cases where medical summaries were available.
Results: Studies were categorized into five indications: a) screening in high risk women (n=7), b) search for primary disease in the presence of disease (n=5), c) monitoring of chemotherapy (n=2), d) postoperative assessment of tumor bed (n=9), and e) diagnostic/characterization of primary or recurrent breast cancer (n=59). Results were defined as negative, positive or no impact on clinical management. MRI testing had a positive impact in 62 cases, affecting measurable change in 9 cases. Benefit was seen in screening, diagnosis and postoperative cases. In 15 cases, MRI stimulated investigations.
Conclusion: MRI is a valuable tool in breast imaging and affects management. Further trials are necessary to define clearly the role of MRI and to ascertain whether in cases where beneficial impact on management is noted, there is ultimate impact on outcome.
Y. Liel, H. Castel and D. Alkalay
Background: For the last 35 years, our medical center has been the only referral center and provider of emergency medical services for a well-defined geographic area in southern Israel.
Objectives: To evaluate trends in the incidence of hip fractures in this population.
Methods: The study was based on two surveys done approximately 20 years apart. It included women and men 50 years and older with radiographic evidence of a new hip fracture caused by low impact trauma. Only fractures that resulted from low or moderate trauma were considered for the current study. Incidence rates were calculated based on population data obtained from the official Central Bureau of Statistics.
Results: There was an overall twofold increase in the incidence rate of hip fractures. However, this increase occurred almost exclusively in the over-75 year old age groups (2.5-fold increase, both in women and men). The mean (and median) age of patients with hip fractures increased significantly over the study period, corresponding with the increase in longevity between the two periods.
Conclusions: There was a marked secular increase in the incidence of proximal hip fractures in both genders, primarily because of an increase in the fracture rate in the very old. The increase in median age of fracture patients suggests that the observed increase in fracture rate can be attributed mainly to aging of the population rather than to deterioration in bone quality over the generations.
A. Yellin, S.T. Zwas, J. Rozenman, D.A. Simansky and E. Goshen
Background: Somatostatin receptor scintigraphy has been used widely for the evaluation of neuroendocrine tumors in the gastrointestinal tract. Its use for detecting and staging thoracic carcinoids is only sporadically reported.
Objectives: To evaluate the possible roles of SRS[1] in the management of proven or suspected pulmonary carcinoids.
Methods: We conducted a retrospective study of all patients undergoing SRS for known or suspected pulmonary carcinoids in a tertiary referral center during a 10 year period. During this period 89 patients underwent resection of pulmonary carcinoids and SRS was used for detection, staging or localization purposes in 8 of them (9%). Scans were labeled true positive, true negative, false positive, or false negative in comparison with histologic or follow-up results.
Results: SRS was true positive in 6/6 lung locations; true positive in 2/8, true negative in 4/8 and false positive in 2/8 lymph node locations; and true positive in 1/8, true negative in 6/8 and false negative in 1/8 distant locations. The sensitivity, specificity, positive and negative predictive values and accuracy were 90%, 83%, 83%, 91% and 87% respectively. The scans were strongly positive in the tumors and involved lymph nodes. SRS correctly localized an occult secreting pulmonary carcinoid. Granulomatous and reactive lymph nodes showed increased uptake. SRS was accurate in ruling out distant metastases.
Conclusions: SRS is effective for visualizing and localizing pulmonary carcinoids. It assists in the staging of these tumors by detecting lymph node involvement and confirming or ruling out distant metastases. Inflamatory areas in the lung or lymph nodes may be falsely positive.
[1] SRS = somatostatin receptor scintigraphy
J. Delgado, A.D. Sperber, V. Novack, B. Delgado, L. Edelman, N. Gaspar, P. Krugliak, S. Odes, A.B. Jotkowitz, M. Faszczyk and A. Fich
Background: The epidemiology of primary biliary cirrhosis has changed significantly over the last decade, with a trend towards increasing prevalence in many places around the world.
Objectives: To determine the overall prevalence of PBC[1] in southern Israel and the specific rates for different immigrant groups between January 1993 and October 2004.
Methods: Multiple case-finding methods were used to identify all cases of PBC in the study region. Age-adjusted prevalence rates were compared among the different immigrant groups.
Results: A total of 47 cases of PBC were identified with an overall prevalence of 55 cases per million. All patients were women, and all except for a Bedouin Arab were Jewish. Foreign-born patients comprised 70% of our PBC cohort even though they represent only 45.4% of the regional population. This predominance of immigrants did not change when the rates were adjusted for age (P < 0.001). The prevalence rates were 40, 177, and 58 cases per million for those born in Israel, North Africa or Asia, and Eastern Europe, respectively. The age-specific prevalence rate for women older than 40 years varied from 135 cases per million among those born in Israel to 450 among immigrants from Eastern Europe and the former USSR to 700 cases per million among immigrants from North Africa and Asia.
Conclusions: The prevalence of PBC in southern Israel is similar to that reported from some European countries. The rate is much higher among Jews than Arabs and among immigrants to Israel compared to native Israelis.
J-M. Anaya and Y. Shoenfeld
E. Zimlichman, M. Pitashny, E. Konen and M. Szyper-Kravitz
N. Sharon, J. Schachter, R.T. Talnir, J. First, U. Rubinstein and R. Bilik